Health insurance market reform and employee compensation: The case of pure community rating in New York

Pure community rating, which was enacted to improve access to health insurance in New York's small group market in 1993, prevents carriers from charging different premiums based on the ages of a firm's workers. If small firms were adjusting compensation packages prior to reform to offset higher health care costs of older workers, then community rating could lead to greater relative wages for older workers post reform and not necessarily induce adverse selection that results in changes in who is insured. I present evidence showing that relative wages of older workers in small firms increased in comparison with other states and with large firms within New York following reform.     

城镇基本医疗保险中逆向选择的检验

本文利用城镇居民基本医疗保险试点评估调查的数据,实证检验了我国城镇居民和职工基本医疗保险中的逆向选择问题。本文的实证结果证实了逆向选择的存在:在未被城镇职工基本医疗保险覆盖的城镇人群中,健康状况较差的个体更倾向于参加城镇居民基本医疗;城镇居民基本医疗保险的参保者接受门诊和住院服务利用率的概率更高;保险对住院服务利用率的影响大于对门诊的影响。另一方面,我们还发现在已被城镇职工基本医疗保险覆盖的人群中,健康状况较差的职工也更倾向于购买补充商业医保,但是健康状况最差的个体购买补充商业医保的概率最低,而购买商业医保后住院率显著增加。     

中国居民医疗保险购买行为研究-基于商业健康保险的角度

本文通过健康保险市场供需双方行为分析,构建居民医疗保险购买行为模型,利用中国健康与营养调查数据(2000—2006),运用部分观测的二元Probit估计方法(Bivariate Probit with partial observability),从实证的角度分析商业健康保险市场中供需双方各自的风险选择行为,以及城乡地区居民对商业健康保险的潜在需求行为及其宏微观影响因素。本文发现:(1)城乡居民都存在显著的逆向选择行为;(2)城乡社会医疗保障对居民商业健康保险需求行为有显著的促进作用;(3)影响居民商业健康保险行为的其他因素还包括,个人的风险偏好和经济购买力。     

Choice, price competition and complexity in markets for health insurance

The United States and other nations rely on consumer choice and price competition between competing health plans to allocate resources in the health sector. While a great deal of research has examined the efficiency consequences of adverse selection in health insurance markets, less attention has been devoted to other aspects of consumer choice. The nation of Switzerland offers a unique opportunity to study price competition in health insurance markets. Switzerland regulates health insurance markets with the aim of minimizing adverse selection and encouraging strong price competition. We examine consumer responses to price differences in local markets and the degree of price variation in local markets. Using both survey data and observations on local markets we obtain evidence suggesting that as the number of choices offered to individuals grows, their willingness to switch plans given a set of price dispersion differences declines, which allows large price differences for relatively homogeneous products to persist. We consider explanations for this phenomenon from economics and psychology.     

城镇基本医疗保险中逆向选择的检验

本文利用城镇居民基本医疗保险试点评估调查的数据,实证检验了我国城镇居民和职工基本医疗保险中的逆向选择问题。本文的实证结果证实了逆向选择的存在:在未被城镇职工基本医疗保险覆盖的城镇人群中,健康状况较差的个体更倾向于参加城镇居民基本医疗;城镇居民基本医疗保险的参保者接受门诊和住院服务利用率的概率更高;保险对住院服务利用率的影响大于对门诊的影响。另一方面,我们还发现在已被城镇职工基本医疗保险覆盖的人群中,健康状况较差的职工也更倾向于购买补充商业医保,但是健康状况最差的个体购买补充商业医保的概率最低,而购买商业医保后住院率显著增加。     

Adverse Selection in Health Insurance Markets: A Classroom Experiment

Adverse selection as it relates to health care policy will be a key economic issue in many upcoming elections. In this article, the author lays out a 30-minute classroom experiment designed for students to experience the kind of elevated prices and market collapse that can result from adverse selection in health insurance markets. The students should come away from the experiment understanding why adverse selection leads to high prices on good quality insurance and why it forces healthy individuals into low quality plans. Additionally, the experiment helps students think about the market characteristics that make health insurance particularly vulnerable to problems of asymmetric information. Finally, the experiment connects the adverse selection problem with key features of the 2010 Patient Protection and Affordable Care Act.     

SEPARATE AND UNEQUAL: THE EFFECT OF UNEQUAL ACCESS TO EMPLOYMENT-BASED HEALTH INSURANCE ON SAME-SEX AND UNMARRIED DIFFERENT-SEX COUPLES

Employers' health insurance coverage for legal spouses places unmarried couples at a disadvantage for obtaining coverage. Data from the Current Population Survey confirm that people with same-sex or different-sex unmarried partners are two to three times more likely to be uninsured than married people, even after controlling for factors influencing coverage. Universal partner coverage would cut that uninsured rate by as much as 50%. Employers offering domestic partner benefits would see a small enrollment increase: 0.1%–0.3% for gay and lesbian partners and 1.3%–1.8% for heterosexual partners. We find no evidence of adverse selection. (JEL J32 , J38 , J71 )     

Why is the market for long-term care insurance so small?

Long-term care represents one of the largest uninsured financial risks facing the elderly in the United States. We present evidence of supply side market failures in the private long-term care insurance market. In particular, the typical policy purchased exhibits premiums marked up substantially above expected benefits. It also provides very limited coverage relative to the total expenditure risk. However, we present additional evidence suggesting that the existence of supply side market failures is unlikely, by itself, to be sufficient to explain the very small size of the private long-term care insurance market. In particular, we find enormous gender differences in pricing that do not translate into differences in coverage, and we show that more comprehensive policies are widely available, if seldom purchased, at similar loads to purchased policies. This suggests that factors limiting demand for insurance are also likely to be important in this market. Our evidence also sheds light on the likely nature of these demand-side factors.     

Minimum standards, insurance regulation and adverse selection: evidence from the Medigap market

This paper examines the implications of minimum standards for insurance markets. I study the imposition of binding minimum standards on the market for voluntary private health insurance for the elderly. The central estimates suggest that the introduction of the standards was associated with an 8 percentage point (25%) decrease in the proportion of the population with coverage in the affected market, with no evidence of substitution toward other, unregulated sources of insurance coverage. To explore possible factors contributing to the impact of the minimum standards, I develop comparative static predictions of the impact of imposing minimum standards in an insurance market with adverse selection. The observed changes in market equilibrium associated with the minimum standards are broadly consistent with these predictions, providing evidence of the existence of adverse selection in this insurance market. More importantly, they suggest that the presence of adverse selection—which in principle may provide an economic rationale for minimum standards—in practice may have exacerbated the declines in insurance coverage associated with the minimum standards.     

The determinants of the demand for private health insurance under Medicare

Since the introduction of Medicare in 1984, the proportion of the Australian population with private health insurance has declined considerably. Insurance for health care consumption is compulsory for the public health sector but optional for the private health sector. In this paper, we explore a number of important issues in the demand for private health insurance in Australia. The socio-economic variables which influence demand are examined using a binary logit model. A number of simulations are performed to highlight the influence and relative importance of various characteristics such as age, income, health status and geographical location on demand. A number of important policy issues in the private health insurance market are highlighted. First, evidence is provided of adverse selection in the private health insurance pool, second, the notion of the wealthy uninsured is refuted, and finally it is confirmed that there are significant interstate differences in the demand for private health insurance.     

Genetic adverse selection: Evidence from long-term care insurance and Huntington disease

Individual, personalized genetic information is increasingly available, leading to the possibility of greater adverse selection over time, particularly in individual-payer insurance markets. We use data on individuals at risk for Huntington disease (HD), a degenerative neurological disorder with significant effects on morbidity, to estimate adverse selection in long-term care insurance. We find strong evidence of adverse selection: individuals who carry the HD genetic mutation are up to 5 times as likely as the general population to own long-term care insurance. This finding is supported both by comparing individuals at risk for HD to those in the general population and by comparing across tested individuals in the HD-risk population with and without the HD mutation.     

Health insurer market power and primary care consolidation

This paper analyzes how health insurance market concentration impacts the market structure of primary care physicians. In more concentrated insurance markets, physicians are found to work in larger practices and their practices are more likely to have a hospital with an ownership interest. Physicians are also less likely to report being in a competitive physician market, consistent with practice consolidation. Our results suggest that consolidation in insurance markets impacts the competitive structure of physician markets.     

Does health insurance reduce illness-related worker absenteeism?

The objective of this article is to examine whether having health insurance reduces illness-related absenteeism among older workers. A nationally representative sample of 1780 workers in the United States, aged 52–64, are drawn from the 2004–2006 Health and Retirement Study (HRS). Binary logistic regressions and censored Tobit models are estimated for workers’ likelihood of missing work days due to illness and the number of illness-related work days missed, respectively, while explicitly addressing the possibility of insurance-selection effects. The findings suggest that over a 12-month period, older workers without health insurance are as likely as insured workers to miss work days due to illness and there are no differences in the number of days missed between insured and uninsured workers. However, there is strong evidence that poor baseline health, onset of new diseases and longer hospitalization significantly increase an older worker's absenteeism at work. These results suggest that having health insurance does not affect illness-related absenteeism among older workers in the US. Future research examining other aspects of worker productivity, such as ‘presenteeism’, and the longer term effects of insurance on productivity can extend our understanding of the role of health insurance in the workplace.     

Does asymmetric information matter in the early insurance market? Evidence from the auto insurance market

In the late 1960s, the performance of automobile insurance declined dramatically in Japan in spite of rapid growth in the diffusion rate, and the premiums were sharply raised several times in order to improve the situation. This observation indicates the possible presence of adverse selection (death spiral), and provides an ideal situation for assessing informational asymmetry. Using bodily injury liability (BIL) insurance data from 46 Japanese prefectures over the period 1966 to 1975, this article tests two hypotheses of adverse selection: (i) high-risk drivers were more likely to join the BIL insurance market and (ii) sharp premium increases drove low-risk policyholders away. Various empirical analyses show that there is little evidence for either type of adverse selection. We also test whether a risk-misperception hypothesis can explain our results, and find some evidence that the population density have a significantly positive impact on the demand for BIL insurance.     

The wealth effects of premium subsidies on moral hazard in insurance markets

Insurance premium subsidies are present in many insurance markets. The Swiss government, for example, paid out CHF 4.26 billion or 0.72% of the Swiss GDP for health insurance premium subsidies in 2011. Analyses of premium subsidies have often highlighted that the increased insurance demand due to premium subsidies increases the effects of moral hazard in the market. Other consequences of premium subsidies, however, have mostly been neglected by the literature. We show in our theoretical model that the wealth effects of premium subsidies decrease the sensitivity of the insured towards the monetary consequences of losses. This leads to less prevention efforts by the insured and thus increases moral hazard in the market. The effect is preserved if the subsidy is financed through proportional taxation. Using two alternative models, we show that providing state-dependent subsidies can either increase or reverse this effect, depending on which state subsidies are paid. We argue that whether demand effects or wealth effects of premium subsidies will dominate the insured׳s behavior depends on the market structure.     

Private Information in Life Insurance,Annuity, and Health Insurance Markets

Economic theory predicts that private information on risks in insurance markets leads to adverse selection. To counterbalance private information, insurers collect and use information on applicants to assess their risk and to calculate premiums in an underwriting process. Using data from the English Longitudinal Study of Ageing (ELSA), this paper documents that differences in the information used in underwriting across life insurance, annuity, and health insurance markets attenuate private information to different extents. The results are in line with – and might help to reconcile – the mixed empirical evidence on adverse selection across these markets.     

A Critique of the Private Health Insurance Regulations

The private health insurance sector is one of the most regulated sectors in Australia. The Private Health Insurance Incentives Scheme, along with community rating, is intended to make private insurance equitable, profitable and popular. We argue that the subsidy to health insurance ought to be a very effective tool for increasing insurance–but it was ineffective because community rating was ineffective. Using data from the Household Expenditure Survey we find that despite community rating rules which prohibit age‐adjusted premiums, young adults paid considerably less for their insurance than older adults. We conclude that insurers circumvented community rating through plan design, screening older consumers into more expensive plans. We also find that the penalty of 2 per cent per year for delaying insurance, introduced as part of the lifetime cover plan, is too low to be effective. We reflect on the New Zealand experience, where a completely deregulated insurance industry continues to be profitable and enjoys similar rates of coverage to those of Australia, and we ask whether Australia too could not benefit from complete deregulation.     

The welfare effect of income tax deductions for losses as insurance: Insured- versus insurer-sided adverse selection

Kaplow (1992) shows in a complete-information environment that allowing income tax deductions for losses as partial insurance is undesirable in the presence of private insurance markets. This paper elaborates on Kaplow's finding by studying two extreme types of asymmetric information structures in private insurance markets: Either the insured or insurers possess superior information. It is shown that our derived result is consistent with Kaplow's if the insured have superior information; however, Kaplow's negative conclusion with respect to the income tax deduction will be overturned if insurers have superior information instead. A policy implication from our finding is that whether or not to allow an income tax deduction for losses needs to be more refined and, specifically, it should be tailored to the “adverse selection” information structures of private insurance.     

Adverse selection in annuity markets: Evidence from the British Life Annuity Act of 1808

We study adverse selection using data from an 1808 Act of British Parliament that effectively opened a market for life annuities. Our analysis indicates significant selection effects. The evidence for adverse selection is strongest for a sub-sample of annuitants whose annuities were purchased by profit-seeking speculators, a sub-sample in which “advantageous selection” resulting from multi-dimensional heterogeneity is unlikely to have been significant. These results support the view that adverse selection can be masked by advantageous selection in empirical studies of standard insurance markets.     

Taxation,insurance, and precautionary labor

We examine optimal taxation and social insurance with adverse selection in competitive insurance markets. In a previous literature, it has been shown that, with perfect insurance markets, social insurance improves welfare since it is able to redistribute without creating distortions. This result has been taken as robust to the introduction of adverse selection as this would only provide additional justifications for social insurance. We show, however, that adverse selection can weaken the case for social insurance compared to a situation with perfect markets. Whenever social insurance mitigates private underinsurance, it also causes welfare-reducing effects by decreasing precautionary labor supply and hence tax revenue. In addition, adverse selection may reduce the redistributive potential of social insurance. We illustrate our general results using different equilibrium concepts for the insurance market. Notably, we derive conditions under which a complete renunciation of social insurance is optimal and the government only relies on income taxation to achieve its redistributive objectives.